There is a weird dynamic that occurs in nearly every hospital setting around the country. It’s a hostile dynamic that seems to be older than time and almost hard-wired into everyone that partakes in this seemingly fruitless endeavor known as health care. It’s an Us-versus-Them dynamic which oddly enough seems to pit physicians against nurses.

“That doesn’t make sense. Aren’t they supposed to work together?”

Indeed.

I.

The tension is immediately palpable upon your first day of third year clerkships as a medical student. If you think back hard enough, maybe you can remember the first time you walked unto the floors, asked a nurse a question, and were met with either indifference or resentment. The interaction may have surprised you. It was just a routine question, wasn’t it? Maybe the nurse was having a bad day? Regardless, you continue to solider through in your ignorance while nervously seeing patients and hoping to not make an ass of yourself in front of the attending. However, inevitably, you must approach the nurses again to ask about/for something. You proceed in your seemingly mundane and innocent task but ultimately are still left with the impression that you serve no purpose but to be a pain in their collective asses. Occasionally, you will have interactions with the nurses that are pleasant. Just as there are a handful of surgery residents who do not harbor bitter resentment and rage towards every living thing, there are also nurses who make it a point to interact with the “lessers” as if they were human beings. These interactions are few and far between though. By the end of your fourth year, you have a clear understanding of how things work; you know which train tracks not to cross. And this is just in time for you to begin your residency where you get to see things from a whole new perspective.

Intern year is where you begin to clearly see the divide. At this point in your medical career, you effectively know a lot about nothing. And the nurses know this. At this stage, you are going to screw up, a lot. Like, a lot a lot. You are going to be too conservative in some matters and then too liberal in others. You are going to hedge when talking with family members and give too much hope when there is none to be had. You are going to contradict the nurse, even if you do not intend too, and create tension. The nurses expect this. They have been through it all before. Some nurses may even be able to do your job better than you. But still, and despite this, they are obligated to follow whatever you haphazardly put into the chart; it is a life of Groundhog’s Day just with different actors. They may call you about it, clearly annoyed, and demand you fix it. Or other, more subversive, nurses will follow the order to the T. At this point, animosity often arises and becomes rather obvious even to the dimmest of bulbs. And how do the nurses best convey their frustrations? It’s not by direct confrontation; that is a big No-No as many nurses have often been burned in the past for these types of actions. Their weapon of choice: passive-aggression.

You know it when you see it, the nurses that have taken up their passive-aggressive arms. You will receive a thousand pages for stool softeners, electrolyte replacements, diet orders, Tylenol, anti-emetics, and narcotics. You will never be called doctor; in their eyes, you are a baby doctor that barely knows how to crawl and is always covered in shit. They will interrupt you on rounds to give “updates” that contradict the information you obtained, they will question every decision you make, and they often will “go up the chain” when they disagree with you until they get an answer they like. And they will do this all in the name of “patient advocacy” because it is the ultimate trump card; it is the equivalent of invoking God’s Will as the reason for your actions. And as this goes on, as the pages piles up, and as the years tick by, things may get a little better. Eventually, you become the senior resident and no longer have to field the majority of pages, you are not presenting during rounds, and you are officially higher up on that “chain” where you can have a final say. But the memory of the past still haunts you, it still leaves a bitter taste in your mouth. Again, there were nurses along the way that were decent, amiable, and easy to interact with, but their light has been extinguished by the mounds of shit which was otherwise known as your day-to-day. And as you near the end of your indentured servitude, filled with the ugly memories of your war days, you hold on to that world-view of “Us-versus-Them” as you transition into becoming the illustrious Attending.

As an attending, you are now addressed as “Doctor”. Much of the overt rudeness you may have experienced as a resident appears to have quickly disappeared. You are at least given the impression of having more respect. And right or wrong, sometimes you may even feel like you earned it, so now you make your move. When you receive a page or call from nursing regarding a less than pressing matter, you lash out, belittle, or demand further information and a call back before hanging up. You demand to be called “Doctor”. You have little or no regard for how the timing or placement of your orders may inconvenience the nursing staff and may even erupt in a fit of indignation when something was not done perfectly the first time. And the best part? Despite occasionally acting like an impetuous child, no one will call you on it. You are the boss! Absolute power corrupts absolutely.

But despite the fact that the nurses may not outright call you a flaming dick bag to your face, they sure as hell are seething about it when you are nowhere to be found. They hate how you respond to requests for orders or information, despite the fact that it is their job to make such requests. They brace for impact when they see your name on the chart and have likely bitched to various supervisors which ultimately have no power to make changes. They will likely still use their tried and true method of passive aggression on you, which will be irritating, but you are still in control. They know that. And they hate that. And that hatred, since it can’t be paid back, is paid forward. And the cycle continues.

II.

It may appear that I have put all of this on the nurses, that I have accused them of throwing the first stone. Let me assure you, I have not. I do not know if anyone will ever know who drew first blood in this seemingly endless war as this information is likely lost in time. If I had to wager a guess though, I would bet on the physicians as cause of the initial insult. Unlike the role of physician, residents have only been a fairly recent phenomenon. Back in “the day”, many physicians just did apprenticeships with anyone that would have them, regardless of any true credentials. There were no large, urban hospitals, health insurance reviews, M&M conferences, practice standards, malpractice, or even many legitimate treatments. Hell, nursing was not even a profession until the mid-1800s and seemingly in response to most nurses at the time being rowdy drunks and assholes. Seriously. So taking this into account, I imagine that physicians may have had to be raging ass hats towards a certain percentage of the nursing staff to distract them from their gutter whiskey long enough to perform a task that could have potentially been life-saving. Or unwittingly tortuous. Back then, it was kind of hard to tell which it was. Assuming this to be correct, or close enough, this culture has seemingly persisted throughout the ages despite the unfortunate lack of alcohol and boxing matches currently allowed in modern hospitals. But now, the physicians are not just magically appearing “fully trained” and the nurses find themselves in a position of relative power during the physician’s formative years. Let the hazing begin!

But the origin of blame is not the point. Assigning blame in this eternal conflict only distracts from the more salient issue of why this system is even in place. What good comes from the perpetuation of the “Us-versus-Them” culture? Is it good for the patients? Is it good for the hospital? Answer: It’s good for the system.

III.

It’s all about control. As I have already elaborated on, you need to distract and demoralize those you intend to control in order to make them accept your command without question. This is especially true when the servants possess the power; you need to make sure they never use it. In our current system, the nurse resents the physician for built-in subservience and the physician resents the nurse because they seemingly make their job, and by extension, life more difficult. Both camps seem to be too caught up in the conveniently constructed struggle to notice that they have a mutual adversary: the patient.

It is no secret among the health care community that the vast majority of patients that are encountered in the hospital setting are nothing more than morbidly obese, cognitively impaired, adult-themed children that are hyper-focused on the irrelevant. These patients seek nothing more than narcotics and food and invariably complaint about both the speed in which they are acquired and the pleasure that is derived. I’ve had multiple patients come in unable to breath and demand a hamburger, mashed potatoes, and soda; I’ve offered them hospice with only a minimal amount of facetiousness. Sadly, they never take me up on it. Instead, they somehow find a way to survive their hospitalization with only a minimal number of aspiration events and are eventually released back into the wild to inevitably be re-admitted again.

These “patients” serve as the impetus for the eternal conflict. They are the initial reaction that sets off a cascade of events resulting in frustration. These are the patients that the nurse is constantly calling about narcotic orders, diet orders, non-compliance with treatment, need for frequent updates, and threats of leaving AMA. These are the patients that the doctor hears about ad-nauseam that lead to a full rage meter and broken pagers. It is these patients that serve as the kindling which ignites the fire that consumes any chance of decent working relationships. They are the central cog in the system’s design however their ignorance is so great that I doubt they even understand the role in which they play; the role of the unilateral rage generator.

No matter how horrible and ridiculous they may be, patients are untouchable, especially in this era of “Health care as Business” where they will soon be referred to solely as “customers”. Save for some likely isolated incidents, the nurses are not yelling back at the patients, they are not (rightfully) telling them to go fuck all the way off, and they are not refusing ridiculous requests. Similarly, most physicians will allow these patients to run right over them in an attempt to save time by avoiding conflict in the hopes of still obtaining that coveted “9 out of 10”. Sure, some of the really crazy ones get their Haldol levels replenished, but this is not the norm.

So, what happens with this rage? Well, as alluded to above, it bounces back and forth between the physician and nurses until all they can see is their respective disdain for each other. And this does not just happen once a day, this happens several times a day. The battle royale known as “physician vs nurse” is continually powered all to the delight of the system; we are nothing but dancing puppets.

But the system is not happy with just physicians and nurses pitted against each other. The system has set up redundant circuits of in-fighting. Have you ever seen the ICU and PCU nurses get along? Have you ever seen the PCU and general floor nurses get along? How about different physician subspecialties? One could answer “yes” to any of the above, but they could not truthfully claim that it is the norm.

IV.

Think about what could happen if physicians and nurses suddenly woke up one day and began to work together. What if we started to direct our energies away from tearing each other apart and instead focused those energies on demanding patient reform? What if those energies were directed towards the bureaucrats and administrators that set the arbitrary rules which seem to govern our lives? What if those frustrations and anger were directed towards the national health care debate in an attempt to bring to light the true issues which make health care expensive? What if instead of focusing on our own bickering when faced with irrational regulations, we simply provided a collective reply of “I prefer not to”?

But unfortunately, there are dilaudid orders to place and nurses to chew out. So I guess we’ll never know.